Doctor, My Head Hurts!

DOCTOR, MY HEAD HURTS

February was the last of my three months at Family Medicine clinical rotation. In addition to normal clinical consultations, we also had to take turns attending spontaneous demands coming “from the street”, in a primary care resource center that works similar to a green zone setting in the ED. During these three months, I’ve noticed that, sometimes, the easiest patient to manage is that one with a major complaint like chest pain, severe dyspnea, altered mental status, and so on. Things become more difficult, however, when you have a patient that has just a headache, a very common symptom, but one that could be related to an enormous variety of conditions, some of which life-threatening. Sometimes, you dig under the “green” patient and discover a secret “yellow” or even a “red” condition.

Next, I will try to put some light on the investigation of one of the most common complaints I’ve seen, and one of the symptoms that always put a bug in the ear: Headache.

Epidemiology

Headache is a very common complaint at the Emergency Department, being the fifth leading cause of ED visits¹. Alarmingly, about 0.5% of patients who had presented with a headache and discharged home have returned with a serious condition, of which 18% were acute ischemic stroke.²

Clinical Presentation

Patients can describe headache, a very nonspecific and hard to clarify complaint, in diverse ways, ranging from saying solely “my head hurts” to making a circular gesture around his/her head with. Therefore, identifying potential risk factors that can alert us to potential adverse outcomes. Here are a few decision rules for patients with headache:

SNNOOP10

The mnemonic SNNOOP10³ refers to the red flag symptom and findings to screen, which may point to related secondary headaches.

snnoop10

Ottawa Subarachnoid Hemorrhage Rule

Ottawa Subarachnoid Hemorrhage Rule fundamentally helps to rule out (Sensitivity: 100% Specificity: 15%) subarachnoid hemorrhage (SAH) in patients with headache. You can apply this rule ONLY IF:

  • The patient is alert and older than 15 years old with
  • New severe non-traumatic headache, reaching maximum intensity within 1 hour and
  • NO new neurological deficits, no history of intracranial tumors, previous SAH or aneurysms, and similar headaches (≥ 3 episodes over ≥ 6 months)

Risk factors are:

  1. Age ≥ 40
  2. Neck pain or stiffness
  3. Witnessed loss of consciousness
  4. Onset during exertion
  5. “Thunderclap headache” (defined as instantly and immediately peaked pain)
  6. Limited neck flexion on examination (defined as the inability to touch chin to chest or raise head 3 cm off the bed if supine)

If ANY of these factors is present, SAH can not be ruled out, and this patient needs further investigation. A recent study has assessed the performance of the Ottawa decision rule for patients presenting with headache in the ED, showing that it is a highly sensitive test (100%), making it useful in order to “not miss the disguised red patient.”5 Not by coincidence, Tintinalli’s book states with bold letters: “Acute onset of a severe headache is subarachnoid hemorrhage until proven otherwise.”

Acute onset of a severe headache is subarachnoid hemorrhage until proven otherwise.

Tintinalli's Comprehensive Study Guide Tweet

Investigation

Neuroimaging is a valuable diagnostic tool but is also an expensive one. Besides, it can be harmful due to radiation exposure or contrast use.

There is a lot of controversy in the literature regarding the question “When to image patients with a headache?”, but the consensus is to image when a patient presents with red flags, especially those related to vascular causes, raised intracranial pressure and focal signs.4

CT scan is the preferred method to investigate SAH, with excellent sensitivity and specificity (both bigger than 90%) in the first 6 hours of hemorrhage.6 However, if more time has passed, other diagnostic tools will probably be required in this case. Also, as said before, the costs are a major factor regarding neuroimaging, and sometimes you have to use what you have.

Lumbar Puncture

  • Indications7:
    • Suspected infectious disease of the CNS
    • Suspected SAH
    • Suspected idiopathic intracranial hypertension – as diagnostic and treatment
  • Contraindications7:
    • Coagulopathy (including anticoagulant drugs) or thrombocytopenia
    • Infection at the puncture site
    • Suspected epidural abscess
    • Findings on the CT scan to deferring LP
    • Brainstem herniation
    • Mass with signs of compression of the 4th ventricle
    • Signs of increased intracranial pressure or midline shift
    • Acute intracranial hematoma

Disposition and Follow-up(7,8)

  • Most patients can be discharged with a simple painkiller prescription. About 95% of patients presenting to the ED with headache have a benign etiology and don’t need further investigation in the ED.
  • The acute benign headache usually resolves with acetaminophen, NSAIDs, hydration, and rest.
  • An adequate follow-up plan is a good practice since most headaches are due to chronic conditions that may benefit from pharmacologic prophylaxis as well as lifestyle modifications.

This subject is open to discussion. Although it looks (and it is) a simple and easy-to-manage condition 90% of times, it has the potential to give the doctor some headache, too!

References and Further Reading

  1. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Acute Headache:, Godwin, S. A., Cherkas, D. S., Panagos, P. D., Shih, R. D., Byyny, R., & Wolf, S. J. (2019). Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache. Annals of emergency medicine74(4), e41–e74. https://doi.org/10.1016/j.annemergmed.2019.07.009
  2. Dubosh, N. M., Edlow, J. A., Goto, T., Camargo, C. A., Jr, & Hasegawa, K. (2019). Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain. Annals of emergency medicine74(4), 549–561. https://doi.org/10.1016/j.annemergmed.2019.01.020
  3. Do, T. P., Remmers, A., Schytz, H. W., Schankin, C., Nelson, S. E., Obermann, M., Hansen, J. M., Sinclair, A. J., Gantenbein, A. R., & Schoonman, G. G. (2019). Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology92(3), 134–144. https://doi.org/10.1212/WNL.0000000000006697
  4. Good C. (2019). British Society Of Neuroradiologists Guidelines for Headache. Retrieved July 23, 2020, from https://bsnr.org.uk/_userfiles/pages/files/standards_and_guidelines/bsnr_guidelines_for_imaging_in_headache_april_2019_final.pdf
  5. Wu, W. T., Pan, H. Y., Wu, K. H., Huang, Y. S., Wu, C. H., & Cheng, F. J. (2020). The Ottawa subarachnoid hemorrhage clinical decision rule for classifying emergency department headache patients. The American journal of emergency medicine38(2), 198–202. https://doi.org/10.1016/j.ajem.2019.02.003
  6. Kwiatkowski T. and Friedman B. W. (2018). Headache Disorders. In: R. M. Walls, R. S. Hockberger, M. Gausche-Hill, K. Bakes, J. M. Baren, T. B. Erickson, A. S. Jagoda, A. H. Kaji, M. VanRooyen, R. D. Zane, (Eds.) Rosen’s Emergency Medicine Concepts and Clinical Practice (9th ed. pp: 1265-1277). Philadelphia, PA: Elsevier.
  7. Perry, J. J., Stiell, I. G., Sivilotti, M. L., Bullard, M. J., Emond, M., Symington, C., Sutherland, J., Worster, A., Hohl, C., Lee, J. S., Eisenhauer, M. A., Mortensen, M., Mackey, D., Pauls, M., Lesiuk, H., & Wells, G. A. (2011). Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. British Medical Journal (Clinical research ed.)343, d4277. https://doi.org/10.1136/bmj.d4277
Cite this article as: Arthur Martins, Brasil, "Doctor, My Head Hurts!," in International Emergency Medicine Education Project, August 24, 2020, https://iem-student.org/2020/08/24/doctor-my-head-hurts/, date accessed: September 25, 2021

Question Of The Day #4

question of the day
question of the day 4

Which of the following is the most appropriate next step in management for this patient‘s condition?

This patient describes her headache as severe, sudden-onset, and different than her prior headaches. These clues on history should raise concern for a subarachnoid hemorrhage (SAH) as the cause of her headache. Choice A (Lumbar Puncture) helps evaluate headaches caused by meningitis, pseudotumor cerebri (idiopathic intracranial hypertension), and SAH. Choice B (IV 1000mL 0.9% NaCl) is sometimes used to treat headaches, like migraines, but this patient should first receive another testing as there is a concern for SAH. Choice C (IV Ceftriaxone) is the correct initial treatment for bacterial meningitis, but this patient has a higher pretest probability for SAH. Choice D (Non-contrast CT head) is the right answer. Non-contrast CT scan of the brain performed within 6 hours of headache onset have high sensitivity to rule out aneurysmal SAH. The sensitivity of the non-contrast CT scan diminishes to 91-93% at 24hours after headache onset and continues to decrease after this to 50% sensitivity at seven days after pain onset. Lumbar puncture is recommended for a patient with a negative CT scan, high pretest probability for SAH, and presentation after 6 hours of headache onset. Findings on Lumbar Puncture that support the diagnosis of SAH include Xanthochromia (yellow appearance of the CSF due to blood breakdown) and inadequate clearing of red blood cells in the CSF between tubes 1 and 4. Treatment for SAH includes blood pressure control, seizure prophylaxis, and neurosurgical consultation, and nimodipine to prevent vasospasm and rebleeding. The Hunt and Hess scoring system can be used to predict clinical outcomes for patients with SAH. Correct Answer: D

Reference

Nelson AM, Mase CA, Ma O. Spontaneous Subarachnoid and Intracerebral Hemorrhage. “Chapter 166: Spontaneous Subarachnoid and Intracerebral Hemorrhage”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

Cite this article as: Joseph Ciano, USA, "Question Of The Day #4," in International Emergency Medicine Education Project, July 15, 2020, https://iem-student.org/2020/07/15/question-of-the-day-3-2/, date accessed: September 25, 2021

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: September 25, 2021

Headache – A Telephone Encounter

Headache - A Telephone Encounter

Learning happens in between cases in the ER. Be it a well-managed case by your colleague or a particular procedure you could have done differently. You learn something after each encounter. At times, learning happens when most unanticipated. Like when you are about to snuggle into your warm bed after a tiring day at the ER. My night was supposed to be calm, maybe punctuated by some calls by a concerned parent of minor flu ridden child, but calm nevertheless. You would not have completed rehearsing your thank you message that you are going to say the day after to the scheduler and the telephone rings. You pick it up because that is literally the only job description for tonight. Answer health queries that people might have. No wonder I was brave enough to feel cozy on the bed in the telemedicine room. It was a call from a 37-year-old female who lived in a village almost 3 hours from Patan Hospital, where I was.

At Patan Hospital, a telephone-based telemedicine service is provided 24/7 via doctors and interns working in the ED. Telephone encounter with a patient has its own challenges. For one, you don’t get to see the patient and hence won’t be able to tell the degree of discomfort. All your Sherlock Holmes like sharp power of observation that you have built through years of practice can only use one of the multiple senses. Listening becomes not only the most crucial skill but the only available tool you have.

Fear to land in the wrong place

Sometimes, you hear that one word that triggers the fast-acting, decisive and flight or fight-mode-run emergency physician in you. That forces you out of habit to think parallel while taking history. A boon and a curse in its own might, differential diagnosis starts popping up and canceling themselves. The goal is either 1) providing the patient reassurance that nothing serious is going on and she can visit a primary care in convenience or 2) urging them to visit the nearest ER because something sinister might be going on. The division seems very black and white but the near distance between the two divisions is so big that you fear to land in the wrong place without a return ticket.

Differentiating headaches

For a starting practitioner that I was, differentiating primary headaches was easier in a precisely articulated MCQ but rather difficult in a real patient scenario.

Temporally jumbled case history, intersecting symptomatology, and vital clues to the diagnosis buried underneath a mist of unrelated information constitute a patient history. To dissect through that mist and reach a sensible differential is an art that comes with practice. As I am sure I will reiterate in years to follow, I hadn’t honed the art form to the degree I have now. I present to you a telephone conversation between an intern on duty at telemedicine and a patient with a headache.

Telephone encounter

Patient

Hello! I have a bad headache.

Me

Hi, I am sorry you have a headache. Let’s talk for a bit; I will try to quickly characterize your headache and advise you on what to do next. Does that sound like a good plan?

Patient

mm hmm. I haven’t had this bad headache ever.

‘First or worst headache’ - this sounds like SAH.

Me

On a scale of 1 to 10, how bad is it?

Patient

I would say 8!

Headache severity

Me

When did it start?

Patient

Around 2 hours ago.

Me

Have you had comparable headaches or headaches on a regular basis?

Patient

Sometimes. I don’t remember.

Me

Do you remember how your headache started? Have you hurt your head?

Trying to rule out the obvious causes like trauma.

Patient

No, I came back from work. At first, I felt nauseous. Then the head gradually started throbbing. It felt like a drum was beating in my head.

At that point, I decided to open up UptoDate and look through the causes of thunderclap headache. SAH, cerebral infections, HTN crisis, Ischemic stroke, cerebral venous thrombosis – the list continued. (1)

Me

Apart from nausea, do you have any other symptoms?

Patient

I am finding it difficult to stay in bright light.

Photophobia! Could this be meningitis or migraine?

Me

Do you feel feverish?

Patient

No

Me

Any rash?

Patient

None that I see.

CNS infection checked off. I feared that I was asking too many questions. Had she presented to the ER, I would have managed her pain first, ruled out my differentials with history taking and sent her for appropriate investigations. The inability to accurately assess the degree of pain further adds to the limits of telephone medicine – you have to trust what you hear without having the opportunity to manage in real-time. History is essential to a proper recommendation, especially when that is the only tool you have – I thought to myself.

Me

Do you have any trouble seeing or walking?

Patient

No

She has been answering well, so no difficulty in speech - her neurological status seems intact.

Me

Do you have any other medical problems? Are you under any medication?

Patient

No. I just took paracetamol but it was of no use.

Me

Do you have nasal congestion or discharge?

Patient

Not now, but I had the flu a week back.

Acute sinusitis is another common cause of headache. (2) Having ruled out serious threatening causes of headache. I was relieved – this sounded like a case of the primary cause of headache, a common presentation in every ER. I needed to remember the differences between different primary headaches – a quick UpToDate search away. Maybe, telemedicine does have some pros – like searching up the internet might not have been very appropriate while talking to your patient.

Me

Where is your pain? Does the pain seem to spread to any other area?

Patient

It’s just in front of my head.

Me

Did you feel anything abnormal before the headache started?

Trying to rule out any aura

Patient

No

Me

Do you feel the urge to isolate yourself and not hear loud noises.

Patient

No. Not really.

Me

From my evaluation, you seem to be having a tension headache. It is not a serious condition and is the most common cause of people presenting with headaches. (3) But I would suggest you visit your nearby health center to ensure you get the right diagnosis nonetheless.

Learning is the summation of moments

Learning is the summation of moments we really understand something, those aha moments, ones that feel like an epiphany. I always knew photophobia and phonophobia occur in migraine and not in tension headache. I may even have read before that day that one of those can happen in tension headache as well. But never had I ever imagined that one day I would reassure a patient that she has a tension headache because she doesn’t have both. The nature of medicine is such that we really learn something after each encounter.

References

  1. Schwedt TJ. Overview of thunderclap headache. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/overview-of-thunderclap-headache
  2. Dodick D. Headache as a symptom of ominous disease. What are the warning signals?. Postgrad Med. 1997;101(5):46–50,55–6,62–4.
  3. Jensen RH. Tension-Type Headache – The Normal and Most Prevalent Headache. Headache 2018; 58:339.

Further Reading

Cite this article as: Sajan Acharya, Nepal, "Headache – A Telephone Encounter," in International Emergency Medicine Education Project, January 20, 2020, https://iem-student.org/2020/01/20/headache-a-telephone-encounter/, date accessed: September 25, 2021

A 24-year-old woman presents with headache

by Stacey Chamberlain

A 24-year-old woman presents with headache that began three hours prior to arrival to the ED. The patient was at rest when the headache began. The headache was not described as “thunderclap,” but it did reach maximum severity within the first 30 minutes. The headache is generalized and rated 10/10. She denies head trauma, weakness, numbness, and tingling in her extremities. She denies visual changes, changes in speech and neck pain. She has not taken anything for the headache. She does not have a family history of cerebral aneurysms or polycystic kidney disease. On physical exam, she has a normal neurologic exam and normal neck flexion.

Should you do a head CT and/or a lumbar puncture to evaluate for a sub-arachnoid hemorrhage in this patient?

Ottawa SAH Rule

Investigate if ≥1 high-risk variables present

  • Age ≥ 40
  • Neck pain or stiffness
  • Witnessed loss of consciousness
  • Onset during exertion
  • Thunderclap headache (instantly peaking pain)
  • Limited neck flexion on exam

A CDR to determine risk for sub-arachnoid hemorrhage (SAH) was derived and has been externally validated in a single study. The CDR’s purpose was to identify those at high risk for SAH and included those with acute non-traumatic headaches that reached maximal intensity within one hour and who had normal neurologic exams. Of note, the rule has many inclusion and exclusion criteria that the ED physician must be familiar with and was only derived for patients 16 years or older. The study authors note that the CDR is to identify patients with SAH; it is not an acute headache rule. In the validation study, of over 5,000 ED visits with acute headache, only 9% of those met inclusion criteria. Also, clinical gestalt again plays a role as the authors suggest not to apply the CDR to those who are ultra-high risk with a pre-test probability for SAH of > 50%.

The Ottawa SAH Rule was 100% sensitive but did not lead to reduction of testing vs. current practice. The authors state that the value of the Ottawa SAH Rule would be to standardize physician practice in order to avoid the relatively high rate of missed sub-arachnoid hemorrhages.

Case Discussion

By applying the Ottawa SAH Rule, this patient is low risk and does not require further investigation for a SAH.

Cite this article as: iEM Education Project Team, "A 24-year-old woman presents with headache," in International Emergency Medicine Education Project, May 29, 2019, https://iem-student.org/2019/05/29/a-24-year-old-woman-presents-with-headache/, date accessed: September 25, 2021

Acute Red Eye

Subconjunctival hemorrhage eye.JPG
By Daniel FlatherOwn work, CC BY-SA 3.0, Link

Red Eye chapter written by David Wood from USA is just uploaded to the Website!

Today’s Headache

In case you didn’t encounter headache today!

450 - subacute-chronic subdural haematoma

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!